Selamat Merdeka, Malaysia!
These are great occasions to reflect on the duality of Freedom. We all have a right to freedom, but it brings concurrent duties. We may be free to choose, but we are slaves to consequences. Unfettered freedom promotes harmful individualism, so we need balance to achieve social solidarity.
Those dualities feature in our health system. Our health system goes beyond just hospitals, doctors or medicines. It is also a political, economic, social and cultural institution, because it defines our rights and duties to health, the relationships between young/old and healthy/sick, and how we experience birth, ageing, decay and death. It is nation-building and solidarity-promoting.
Over six decades, we have exercised our duty to build our health system together, supported by a resilient social contract, mostly correct political choices, and a strong Health Ministry (MOH) technocracy. It has exceeded expectations, allowing us to enjoy our rights to strong health outcomes with relatively low financial allocations.
The first thirty years witnessed coherent capacity-building especially in primary care, and rural development. However, the last thirty years have generally seen us bolting ad hoc quick fixes onto our system, reacting to trends instead of anticipating them, and falling prey to the inevitable siloes of large organizations.
Yesterday’s system has fulfilled its historical mission. Today, our system is necessarily gargantuan and complex. Therefore, like other countries, some parts of it are excellent, some parts mediocre, and other parts beginning to fail. Just like others, we’re dealing simultaneously with both timeless and emerging problems.
That reform is needed is not in question. However, it must be thoughtful and deliberate, not knee-jerk or worse, “reform for reform’s sake”. Freedom is a sine qua non for successful reform, especially if we provide it to three groups: the rakyat, the Health Ministry (MOH), and the whole of Malaysia.
Firstly, the lived experience of the individual rakyat must be free from avoidable disease, suffering and pain. This has been generally and increasingly true since the 1970s, thanks to our health system and modern medicine. As both inevitably evolve, health becomes more expensive. The target of Universal Health Coverage (UHC) responds to that evolution; everyone should get the care they need without getting bankrupted.
Unfortunately, the rakyat aren’t (yet) free from those threats of financial catastrophe. Social progress doesn’t stand still; it’s actually a series of ever-higher moving targets. We can embrace UHC as a new priority without thinking we failed. However, without magic solutions, we need a basket-of-solutions for new sources and better uses of funds, and a new social contract.
Secondly, the MOH must be free to lead, build and implement that basket-of-solutions. They must have political and operational freedom to make the best choices possible, using the best scientific, policy and economic evidence. If we agree that Health for All is a supreme aim, then the MOH must be depoliticised and professionalized from the Minister-level down, with bipartisan leadership of high stature.
Two specific freedoms must be accorded to MOH. One, MOH must be free to equally influence the Really Big Political Decisions, especially the role of the private healthcare sector. Currently, these decisions appear to be driven mostly by the Ministries of Finance and Economic Affairs or at the Prime Ministerial-level; MOH cannot be peripheral to such momentous decisions.
Two, MOH must be free from conflicts of interest. Currently, they are simultaneously payer, provider and regulator. If MOH de-conflicts, the resulting structure will be free to operate more efficiently and check-and-balance each other, a la Montesquieu’s doctrine. That structure will inspire public discourse about outputs (i.e. performance and results), richer than the current narrow debates about inputs (i.e. funding and resources) only.
Finally, our freedom for health must be underwritten by a New Social Contract for Malaysia. The social contract that brought us to today is not future-proof. A vast group of youths will be enfranchised in 2023, and they must be equal participants in our health system. Expectations must be managed, lines drawn, duties prescribed; business-as-usual in our under-funded and over-stretched system cannot continue.
In practical terms, Malaysians must be more self-reliant, instead of blindly depending on the government or expensive hospital-based care to assure our health. We must prioritize healthy behaviours and strong primary care. We must accept that social progress is a never-ending chain of problems; if we fix today’s problems, we only graduate to tomorrow’s. If we make difficult but necessary choices today (e.g. gradual social health insurance), we can have a truly inclusive system tomorrow.
How we treat our poorest and sickest reflects our moral priorities as a society. What’s the point of all our Freedom if we don’t use it well? The highest expression of Merdeka comes when we make the difficult, courageous and necessary choices to reform our health system, thoughtfully and deliberately.